Novel H1N1 Influenza June 19, 2009 CHICA Manitoba Evelyn Lo H1N1-the story In April of 2009, CDC was alerted to 2 children in California with a novel strain of H1N1 influenza At about the same time, Mexico reached out to US and Canada asking for help with a cluster of severe respiratory illness Confirmed that some of the Mexico cases had the same strain as California Alert was sent out to public health to look for severe respiratory illness with ties to Mexico June 11, 2009- WHO declares pandemic level 6 indicating new strain with sustained community transmission in at least 3 continents 1
Clinical Aspects Fever (94%), cough (92%), sore throat (66%) 25% diarrhea and 25% vomiting Around 9% requiring i hospitalization ti Age groups: only 5% older than 51 years old, 40% are 10-1818 years Incubation period 2-7 days Diagnostics RT-PCR for swine flu done daily M-F, results back for inpatients in 24-4848 hours Priority to inpatients so need to make sure requisition indicates location of patient, co-morbidities RT-PCR is >95% sensitive for novel H1N1 virus If negative, set up for culture Treatment Mild URTI not meeting ILI criteria No treatment No testing ILI with no co-morbidities, treat if within 48 hrs of onset, if treat, test ILI with co-morbidities, treat even if over 48 hrs, but consult ID SRI- treat even if past 48 hrs, consult ID 2
Infection Control Review of Guidelines Differences with PHAC SHEA position paper Duration of Isolation Routine Practices Perform hand hygiene frequently Wash with soap and water Use alcohol based handrub Teach and encourage Respiratory etiquette for all suspect ILI patients Perform hand hygiene Cough into sleeve/ tissue Wear surgical/procedure mask whenever visitors or staff are in room Droplet/ Contact Precautions Accommodation Single room is preferable Cohorting with other ILI patients if required Separation of minimum 1 meter, if possible 2 Masks Surgical/procedure mask should be worn by HCW within 1 meter (possible 2) of patient Masks should only be worn once, changed if wet, if front of mask is touched and if contaminated by patient secretions 3
Eye Protection Should be worn within 1 or if possible 2 metres of patient Gloves Should be worn when entering room or patient s designated bed space in shared room Remove upon leaving room/bedspace Gowns Only if clothing or forearms will have direct contact with patient Or with frequently touched surfaces/objects which have an increased risk of being contaminated by respiratory secretions Equipment Patient care equipment should be dedicated to the patient Reusable equipment must be cleaned and disinfected before use on another patient Hospital grade disinfectant is effective 4
Aerosol Generating Procedures HCW (everyone in room) Wear N95 mask, eye protection, gloves and long sleeved gown Administrative controls Most experienced personnel Minimum number of personnel Controlled non-emergent manner Sedate if intubation required signage Engineering controls Negative pressure room with air vented directly outside or though hepa unit Single room with door closed if negative pressure room unavailable Environmental controls Discard or clean/disinfect all contaminated equipment before leaving room Procedure List Nebulized therapy Use of bag/valve mask to ventilate patient Endotracheal intubation Open airway suctioning Chest tube insertion or thoracentesis Bronchoscopy or upper airway endoscopy Tracheostomy Sputum induction 5
PHAC guidelines N95 mask if patient has forceful cough and not compliant with cough etiquette Adds taking nasopharyngeal swab, chest physiotherapy as aerosol generating procedure SHEA position paper Asking CDC to back down from N95 use Evidence to date that H1N1 spread as seasonal flu Data for aerosol transmission is minimal Recommends: droplet precautions N95 if aerosol generating procedures but remove np swabs and nebulizing treatment 6
Duration of Isolation Current CDC guideline: Until 7 days after onset of symptoms OR until asymptomatic, whichever is longer HCW prophylaxis WRHA guideline: If unprotected exposure Not wearing N95 during aerosol generating g procedure Not wearing surgical mask within 1-2 meters of coughing confirmed/probable patient No eye protection and had spray in eye offer prophylaxis within 4 days 7